Abstract
A 53-year old male, 151cm tall and 52kg, was referred to the Tsurumi University Dental Hospital for severe dental pain of the left upper jaw (Photo. 1, 2). At 41 years old he had visited a physician for hematuria and short breath, and was diagnosed as suffering from Eisenmenger's syndrome owing to a ventricular septal defect and subsequent pulmonary hypertension. The lesion was considered inoperable and he received pharmacotherapy during his forty days' admission. During the admission echocardiogram and cardiac scintigram were carried out and they revealed the enlargement of left and right ventricles, and mean pulmonary artery pressure was more than 38mmHg. Two years ago, the patient was readmitted to the hospital for forty days with cardiac failure. Since then he had been taking cardiac drugs, furosemide (Lasix(R)), spironolactone (Aldactone(R)) and diltiazem (Herbesser(R)), and he was assessed as NYHA II-III. His blood pressure was 115-140/65-70 mmHg, and pulse rate was 68-89bpm, but percutaneous O2 saturation was 88-93%. Laboratory data showed slight hemoconcentration (Table 1). ECG indicates atrial fibrillation and complete right bundle branch block (Fig. 1). X-ray film of the chest revealed cardiomegaly with cardiothoracic ratio 66% (Photo 3).
Periodontitis was diagnosed and scaling and extractions of the left upper second and third molar teeth and right lower second molar tooth were scheduled for four separate occasions.
Close consultation was conducted with the patient's physician who was aware of the necessity of treatment but also of the potent risk of sudden death. The risk was explained to his family and himself, and informed consent was obtained. He was admitted the hospital the day before the procedure, and a prophylactic antibiotic was administered intravenously from the day before the treatment. Before the treatment, cardiovascular and antishock agents (Table 2), and equipment for resuscitation, all of which were screened from the patient, had been set up. On arrival at the operating theater, ECG, blood pressure and percutaneous O2 saturation were monitored. An intravenous needle was placed on the dorsum manus and 5% sugar solution was dripped. 20% benzocaine (Hurricaine Gel(R)) was applied for the surface anesthesia, and 3% propitocaine with felypressin 0.03U/ml was used for infiltration anesthesia. The record and ECG during the first procedure were shown in Fig. 2 and 3. The procedures on the four occasions were uneventful. After the procedures he had been observed carefully with pulseoxymeter for 30 min, and an antibiotic was administered postoperatively for three days. He also had an uneventful postoperative course.
Patients with Eisenmenger's syndrome usually die at 30-50 years old. Since such patients are thought to be at risk from the aggravation of cardiac problems, complications induced by dental treatment should be avoided as much as possible.
